Free 09331.FH11 - Indiana

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APPLICATION FOR INDIANA TEACHING, ADMINISTRATION, OR SCHOOL SERVICES LICENSE
State Form 9331 (R13 / 4-09) Approved by State Board of Accounts, 2008 The information in this document is confidential according to IC 5-14-3-4(b)8.

INDIANA DEPARTMENT OF EDUCATION OFFICE OF EDUCATOR LICENSING AND DEVELOPMENT 151 West Ohio Street Indianapolis, IN 46204 Toll Free: 1-866-542-3672 Fax: (317) 232-9023 www.doe.in.gov/educatorlicensing

ACCOUNTING CONTROL
Receipt number Transaction number Date received (month, day, year)

* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

INSTRUCTIONS:

1. 2. 3. 4.

Please TYPE or PRINT clearly. Attach money order or cashier's check for $35.00, payable to the State of Indiana. Do not send cash or personal checks. All fees are non-refundable. Submit this application with a Limited Criminal History report. SECTION A - ACTION REQUESTED

Check one of the following:

Original
Check one of the following:

Addition Administration

Renewal School Services

Conversion to 10-year

Teaching
List subject and/or endorsement areas

SECTION B - APPLICANT INFORMATION
Please print your name as you wish it to appear on your license. Name of applicant (last, first, middle) Social Security number * Address (number and street) City State Date of birth (month, day, year) Previous / maiden name T elephone number

(

)

E-mail address ZIP code

SECTION C - LICENSE HISTORY
Last Indiana educator license held (if any) Last name in which license was issued License number Date of issue (month, day, year)

If you are a graduate of a teacher preparation program at an out-of-state institution, have your credentials been evaluated by the Office of Educator Licensing and Development? Yes No SECTION D - EDUCATIONAL BACKGROUND COLLEGES / UNIVERSITIES ATTENDED DEGREE OR COURSEWORK

If yes, when? (month, day, year)

DATE OF GRADUATION OR ATTENDANCE (month, day, year)

STATE

SECTION E - CRIMINAL HISTORY 1. 2. 3. Have you ever been convicted of a felony? Have you been convicted of a misdemeanor since January 15, 1994? Have you ever had a credential, certificate or license to teach denied, revoked or suspended in Indiana or in any other state? Yes Yes Yes No No No

If you answered yes to questions 1 or 2, you must provide a written explanation and court records, including: Chronological case summary Plea agreements (if applicable) Affidavit of probable cause Judgment / Order of Sentencing Charging information Documentation of successful completion / release from any probation Court records may be obtained from the clerk of the court(s). If you answered yes to question 3, you must submit a written explanation and any available documentation. LOYALTY AFFIDAVIT I affirm that the information contained in my application is true and accurate to the best of my knowledge and belief. Misrepresentations made in this application may constitute grounds to deny, suspend, or revoke a license. I solemnly swear (or affirm) that I will support the Constitution of the United States of America and the Constitution of the State of Indiana.
Signature of applicant Date (month, day, year)